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SECTION IV. Nutrition of Refugees


ACC/SCN Statement on Nutrition, Refugees and Displaced Persons
Protecting Refugees' Nutrition with Food Aid
Comments
Statement to Organizational Committee, 27 March 1992, by John Mason, Technical Secretary, ACC/SCN, Concerning the SCN's Report on Nutrition, Refugees, and Displaced Persons

ACC/SCN Statement on Nutrition, Refugees and Displaced Persons

The ACC/SCN considered the position of refugees and formulated a statement, the specific recommendations of which are that:

a) the protection and promotion of the nutritional well-being of affected populations be fundamental goals of agency policy and programmes concerning refugees and displaced persons;

b) the roles, responsibility and accountability of different organizations, and levels within organizations, be reviewed and if necessary re-defined;

c) routine monitoring of affected populations to be mandatory, in terms of quantity and quality of food supplied and consumed, anthropometric status, the presence of specific nutritional deficiencies, and mortality;

d) reports on these matters be made regularly through the UN system to donor governments and UN governing bodies, which themselves should be more probing in asking questions;

e) NGOs, together with UN agencies and host governments, be recognized in practice, as well as officially, as legitimate partners in these processes;

f) the results of monitoring the operation and impact of relief (see c above) should have an immediate influence on the management of relief operations in terms of action to improve nutritional well-being;

g) management should encourage flexibility and - coupled with accountability - devolution of responsibility for decision-making to intermediate and local authorities;

h) agencies should strengthen if necessary their technical capacity, and give due attention in their decision-making to nutrition and other technical considerations;

i) this process should include, at an early stage, decisions on appropriate goals in terms of alleviating malnutrition and specific nutrient deficiency diseases among refugees and displaced persons.


Protecting Refugees' Nutrition with Food Aid

Mike Toole
Centres for Disease Control

Introduction

The number of refugees dependent on international assistance continues to increase rapidly; of the world's 18 million international refugees, approximately 13 million are living in camps in remote areas of Africa, the Middle East, and Southwest Asia. In addition, up to 20 million internally displaced persons are dependent on some kind of international food aid for their survival. Surveys of these populations have demonstrated wide variation in both early nutritional status and in the rate of improvement that has resulted from international food assistance.

The Problem: Protein-Energy Malnutrition

Acute undernutrition prevalence rates have been elevated in many displaced and refugee populations during the past 12 years, ranging as high as 50% in eastern Sudan in 1985 (Tables 1 and 2). Even in 1991, rates were as high as 29% in Kenya, several months after Somali refugees arrived in that country. Undernutrition rates have decreased rapidly in situations where effective emergency relief operations have been mounted promptly, such as Thailand (1979) and Pakistan (1980); however, in other emergencies, such as in Somalia (1980) and Sudan (1985), undernutrition rates have remained high (>20%) for 6 to 8 months. Of even greater concern is the observation that acute undernutrition rates among Somali refugees in Ethiopia (1988-89) actually increased 6 months after a relief programme was launched.

Table 1: Prevalence of Acute Undernutrition among children less than 5 years of age in refugee populations.

Dates

Host Country

Country of Origin

Population

Prevalence % Undernutrition

1979

Thailand

Kampuchea

31,900

10.0-18.0

1980

Somalia

Ethiopia

700,000

21.7-28.4

1984-85

Pakistan

Afghanistan

2,500,000

2.3-3.5

1988

Malawi

Mozambique

400,000

2-1-6.1

1988-89

Ethiopia

Somalia

400,000

12.9-29.5

1990

Guinea

Liberia

400,000

5.3

1990

Ethiopia

Sudan

25,000

45.0

1991

Kenya

Somalia

50,000

29.0

1991

Iraq/Turkey Border

Iraq

400,000

4.1


Table 2: Prevalence of Acute Undernutrition among children less than 5 years of age in internally displaced populations

Date

Country/Region

Population Affected

Prevalence Acute Undernutrition

1983

Mozambique


12-28%

1985

Ethiopia (Korem)

800,000

70%

1988

Sudan (Khartoum)

750,000

23%

1988

Sudan (S. Darfur)

>80,000

36%

1990

Liberia (Monrovia)

500,000

35%


Malnutrition and mortality

While most high acute undernutrition prevalence has been associated with inadequate food rations, it appears that malnutrition developed among Kurdish children 1 to 2 years of age in Turkey within a period of 1 to 2 months, primarily because of the high incidence of diarrhoeal diseases in the camps. The synergism between high malnutrition prevalence and increased incidence of communicable diseases explains much of the excess mortality seen in refugee and displaced populations. A study of 42 refugee populations in 1989 showed a strong positive association between acute malnutrition prevalence and crude death rates (CDR). Populations with acute undernutrition prevalence rates of less than 5% had a mean CDR of 0.9/1000/month. Refugee populations with undernutrition prevalences of >/= 50%, however, experienced a mean CDR of 37/1000/month with a range of 4/1000/month to 177/1000/month.

The close correlation between malnutrition prevalence and crude mortality during a relief operation for Somali refugees in eastern Ethiopia in 1988-89 was clearly demonstrated. Malnutrition prevalence was estimated by serial cross-sectional cluster sample surveys of children less than 5 years and monthly death rates were estimated retrospectively by a population-based survey in August 1989. During the period of high malnutrition prevalence and high mortality (March through May 1989), the crude death rate reached 9/1000/month - 4.5 times greater than the non-refugee death rate in Ethiopia. Food rations provided an average of approximately 1400 kilocalories per person per day instead of the recommended minimum of 1900 kilocalories per person per day.

Likewise, in eastern Sudan in 1985, inadequate amounts of food (1360-1870) kilocalories per person per day) were distributed to Ethiopian refugees during the first five months after their arrival in the camps. Malnutrition rates, as well as mortality rates, remained high during this period.

Table 3. Micronutrient Deficiency Disease Outbreaks in Refugee Camps, 1984-1991

Disease

Year

Location

Prevalence(%)

Scurvy

1984

Sudan

22.0

1985

Somalia

6.9-44-0

1989

Ethiopia

1.0-2.0

1991

Sudan

NA

Xerophthalmia

1985

Sudan

NA

Beriberi

1985

Thailand

NA

Pallagra

1989

Malawi (11 camps)

0.5

1990

Malawi (11 Camps)

6.3

Iron Deficiency

1990

Syria, Jordan,

54.5-73.9

Anaemia


West Bank & Gaza

(Children)



12.5-62.5



(Women)

1990

Ethiopia

10.0-13.0


Micronutrient deficiencies

The importance of micronutrient deficiencies in refugee and displaced populations has only recently been extensively documented. In addition to deficiencies of vitamin A and iron, conditions that have been widely recognized as important childhood problems in developing countries, large epidemics of scurvy and pellagra have also been reported in refugee populations during the past decade (Table 3).

The international community has still not developed an adequate strategy to prevent scurvy in refugee camps in the Horn of Africa, as demonstrated by an outbreak that took place among adult males (former Ethiopian soldiers) in a camp in eastern Sudan during 1991. Scurvy has been closely related to the duration of stay of refugees in remote, African camps (in particular, those for Ethiopian refugees) where food rations have been confined to two or three items. The vitamin C content of these rations has been far below international recommended daily allowances.

An outbreak of pellagra occurred in Malawi among Mozambican refugees between July and October 1989, with 1,169 cases reported in 11 camps where the French agency Médecins Sans Frontières (MSF) was providing assistance; 20% of the cases were in children under 5 years of age. Another outbreak occurred between February and October 1990 with 17,878 cases reported among 285,942 refugees in the same 11 sites, for an attack rate of 6.3%. More than 18,000 cases were reported from all districts hosting approximately 900,000 refugees in southern Malawi, for an overall attack rate of 2.0%. Food rations contained an average of 4.9 mg of available niacin per person per day; the FAO/WHO recommendations for niacin range from 5.4 mg for infants to 20.3 mg for adults. This outbreak occurred when relief efforts failed to include an adequate supply of groundnuts, the major source of niacin in refugee rations.

Risk Factors for Scurvy in Camps for Ethiopian Refugees

- Length of stay in camps
- Age (increased with age)
- Female Sex
- Pregnancy


The lack of variety in basic relief rations is a significant risk factor for pellagra and other micronutrient deficiency syndromes. The inclusion of groundnuts or fortified cereals in daily rations increases the total intake of available niacin and will prevent the development of pellagra.

Risk Factors for Pellagra in Refugees in Malawi

- Young age
- Female sex
- Absence of groundnuts or fish in diet
- Unemployed head of household
- Residence in camp (rather than integrated village)
- Absence of home vegetable garden or poultry


Solutions

The adequacy of the international response to refugee emergencies has been inconsistent, based more on political considerations than on real needs. The avoidance of high malnutrition rates and excess mortality in eastern Thailand (1979) and Pakistan (1980) was probably related to the political importance given to those refugee populations (Cambodians and Afghans) by major donors. In addition, logistical constraints were relatively minor in those countries - both Thailand and Pakistan had important food reserves that could be tapped and fairly good communications and transport capabilities.

The real problems lie in Africa, in particular the Horn of Africa where logistical problems are great and where the political interest among donors is less pronounced. Nevertheless, there have been some successes.

Widespread protein-energy malnutrition was avoided among Liberian refugees in Guinea in 1990; perhaps, we can than the generosity of local Guinean villagers rather than the promptness of the international response. In Malawi, acute undernutrition rates have been low; however, international food aid has been insufficient to avoid large outbreaks of pellagra.

Refugees require the same range of nutrients as other human beings for their survival. The basic human nutrient requirements have long been adequately defined and international guidelines have long existed. If the international community is serious about the protection of refugees, then there has to be an international commitment to protecting refugees from preventable diseases and death. Both protein-energy malnutrition and micronutrient malnutrition among dependent refugees can be readily prevented by the prompt provision of a basic food basket sufficient in quantity and quality. the world's response to refugee and other international emergencies needs to be consistent, based on sound technical assessments, and systematically evaluated to ensure that food and other humanitarian assistance produces the desired impact on the affected population.

There are real practical constraints; the logistics involved in providing an adequate ration to the remote regions of Sudan, Somalia, and Ethiopia are indeed formidable and costly. Regional food reserves, innovative food purchases and exchanges between neighbouring countries, and the use of fortified cereals to provide micronutrients would expedite the prompt provision of adequate food rations. My recent experience with the situation in Russia, however, has taught me - once again - that our political leaders have not yet committed themselves to needs-based humanitarian assistance. Photo opportunities and short-term political agendas continue to dictate the nature of our response to food-related and public health emergencies. Change will only occur if there is a high-level agreement to provide basic human needs to emergency-affected populations, enforced by the type of international conventions that are meant to protect civilians in time of war and which govern the use of nuclear weapons. I will close by proposing a modest goal for the international community to adopt. By 1995, in any displaced or refugee population of 10,000 persons, anywhere in the world, no more than 50 persons should die during the first month of their displacement.

Comments


John Seaman
Basra Hassan
Rita Bhatia

John Seaman

Save the Children Fund, UK

Dr Toole has made a very solid and well documented case for the very poor conditions of refugees, particularly in Africa.

My discussion begins with two preliminary points. Firstly, refugees have a very special status in the world, in countries which are signatories of the Refugee Conventions. There is a responsibility, morally, if not in international law, to see that refugees are well treated. Secondly, as Dr Toole pointed out, food requirements of refugees are not special to refugees. I would like to discuss this further, although it seems obvious, because there has been a great deal of discussion over many years about the recommended ration -- how much food a refugee requires - and there have been endless meetings on this topic, which so far have not reached a completely solid conclusion. There are UN documents recommending rations of 1900 kcals, and I believe the EEC has also moved to introduce the same standards. But there is as yet no general international agreement that refugees have the same food requirements as everybody else, and that these food requirements should be met. To be fair to the UN, I think that one of the reasons for this is their concern that setting standards on food requirements is quite different from actually getting the food delivered, and that if the donors are only providing food from intervention stocks, they are never going to meet such standards. At the same time I think it is very late in the century, and there are, as Dr Toole pointed out, rather a lot of refugees in the world, to still be discussing whether a refugee requires 1900 kcals or 2200, or indeed, as has often been the case, whether one can get away with 1500 or less.

Dr Toole talked about logistical constraints in getting food through to refugee populations. Whilst there is no doubt that these problems exist in remoter areas where refugees are found, we should be careful not to regard this as an easy excuse for inaction. There are very few parts of the world, even in the remoter parts of Africa, which cannot be reached with reasonable effort. In fact, if we take some of the worst cases where refugees have starved, or where refugees have suffered from serious nutritional deficiencies, these have been in countries where logistical difficulties were minimal. There was a case less than a year ago in Sudan where foodstuffs had arrived in the main port, but failed to be delivered to their destination about half a day's drive down a good road. We have a current case in Kenya where the markets are full of food, the budgets are perfectly adequate to buy the food, where the ports are good, the roads are good, but somehow the food has not been delivered.

Dr Toole discussed the problem of inadequate and unsuitable food rations. Could fortification help? Fortification seems a very easy option, but in practice it has turned out to be rather difficult. One option is to fortify donor foods at source, but because milling grains before they are sent has disadvantages - such as reduced storage life and the added cost of bagging the cereals -the problem is how to fortify whole grains? I believe there is a technology available to do this, but it is expensive which would add a considerable amount to the cost of the foods concerned. If fortification is carried out at local level, again there are difficulties. Camp-level fortification has been tried. Cement mixers full of skimmed milk with vitamin C powder have been used for fortification for local use. However, this is not practical in the long-term in large populations if you consider the tonnages involved - the number of cement mixers needed would be very large, as would be the required administrative control. It would not work. The only situation that we have found so far where we have been able to introduce fortification is in Malawi where there is a sophisticated local commercial milling capacity. It has been possible to successfully add niacin to maize meal, and we should be fortifying most of the rations by next year.

Another concern we have about fortification is that, although the current food technology is effective, donors are clearly not enthusiastic about spending large amounts of money on refugees. In the Malawi case, we have already made some effort to see if we can add further nutrients to the maize meal ourselves, and fortification with iron, zinc, and vitamin C has been discussed. Would it be possible, in fact, to get a cocktail of all nutrients and add it to maize meal? We are reluctant to pursue this route for the obvious reason that, although it might be technically possible to keep populations on maize porridge and nothing else, people should be able to get food roughly in the form that they are familiar with and like - a diet is as important as nutrients. Fortification is a fix. It has its place, particularly in the case of B vitamins, but I think that we should not lose sight of the fact that we should be aiming in general to provide foods adequate in terms of quantity and quality to refugees.

Then there is the question of diversification of income. Under some circumstances, refugees may have possibilities of producing their own food. It is true that in many parts of the world, refugees do produce their own food - and in some cases have maintained themselves for many years without any international ration provision at all. But we should not lose sight of the fact that there are large numbers of refugees in parts of the world where this is really not a practical consideration, particularly the semi-arid and arid zones of East Africa where there are large concentrations of refugees - sometimes 30-50,000 - in one place. There really is very little that they can do to secure an additional food supply; they are completely dependent on international gifts.

Dr Toole mentioned the apparent lack of political interest, particularly with regard to Africa, and I think there is no doubt that this exists. Recently, I was involved in discussions concerning a particular case of refugees in East Africa which attracted quite a lot of media attention. It was pointed out that two years ago, the State Department would have wanted to know what was going on. Now, no matter how publicized the situation is, nobody really seems to care about what's happening to Somalis in Kenya. On the other hand, the fact is that aid flows to Africa for refugees are very substantial. Western donors are giving enormous amounts of foodstuffs to some African countries, much of which is going to refugees. Therefore, although in political terms, there is less pressure to put up the money, the fact is that there is still a great deal of goodwill and a very considerable flow of resources. Why, then, do we repeatedly have these problems in Africa? - problems which, as Dr Toole pointed out, amount to outright starvation in some cases, and great epidemics of diseases which have not been see in epidemic form for a century. Surely there has to be some explanation - if we have got the food, if we have got the markets, if we have got the logistics, and by and large we have got the money, what goes wrong? At Save the Children Fund, we have been searching for the reasons very carefully - over a number of years in many cases - and we have come to conclusions which are of a rather more humble and bureaucratic nature than the conventional conclusions. The problems really come down to accountability, and monitoring and evaluation.

If we look at the international law relating to refugees, the one thing that is clear is that UNHCR has no responsibility whatever for the material welfare of refugees. They can act as a conduit for international assistance - they can act of their own volition if they wish - but they have no legal responsibility for the material welfare of refugees. This situation appears to have its origins at the time that refugee conventions were first drawn up after the Second World War when material welfare was not a major consideration. It was an honest piece of legislation and it was drawn up chiefly for refugees in Europe, where countries were poor, but were able to materially support refugees. The overriding consideration was political protection and the legislation was drawn up in those terms. What this legislation has led to is an ambiguity of responsibility within the international system, and between the international system and the host government of refugees. If any resident representative of UNHCR is asked if he or she is responsible for the welfare of refugees, the general answer is no. Who is responsible? Is the host government responsible? How can the host government be responsible when the host government is frequently bankrupt, at war, or having problems feeding its own population? We seem to have a situation where nobody is responsible, and everybody is responsible.

There are no measures of outcome. All the measures are measures of process - dollars committed, tons committed, rations planned. We have no measures within the system of rations delivered, rations dispersed in populations, and nutritional outcome. There is no requirement for the UN, donors, or host governments to actually monitor the conditions of refugees. Assessments are done, but they are done intermittently. They are also, of course, done by non-governmental organizations, which do not have the right to report their findings within the international system. Documents presented, for example, at UNHCR's Executive Committee, do not usually contain accounts of the nutritional conditions of refugees - they do not contain accounts of scurvy, of pellagra, of starvation. They are all about process, they are all about money, they are all about law. Donors are not officially informed of nutritional problems. Having looked closely at the system in several cases, and having been a donor representative myself for some years, I am aware that donors frequently simply do not know what is going on. We tell our donors what we know, and we bypass the system, and sometimes that is helpful; but it is clear that any system that does not have a measure of performance does not amount to a system.

What we need urgently is the requirement that host governments or UNHCR carry out a minimum monitoring of refugee standards and report that back to donors. If donors then choose to do nothing, that is their right in international law, but at least the donors would have been able to make a choice. Currently, we have a situation where donors are only making a choice when things go badly wrong and reports get into the media. We have had five cases in the last 7 or 8 years where these situations have been brought to the media, and on every occasion the situation has been put right. One case took two years, but all the rest had been put right within the space of a few months. It appears then that once donors are aware that they have a major problem, things start to happen. It seems to me that if donors were aware that there was a scandal - outside the newspapers and off the television - then actually this would often secure action. Resident representatives would not be able to experience these situations and not report them if they knew that a wider constituency was aware of what was going on.

I would like to briefly discuss material supplies. I do not think anybody really knows the truth, but there is a general consensus that current commitments of material to refugee populations are sufficient in quantity (although there is also the question of quality). On the one hand, we know that many refugees essentially feed themselves from their own activities, their own resources, their own work, and from agriculture. But quite frequently, these refugees have been receiving full rations, for reasons such as lack of information or political judgement. Afghan refugees have been mentioned as one group who have been extraordinarily well served with food, housing, fuel and cash over a long period of time, where cereals alone would suffice because people could exchange them. At the other extreme, we also have situations where people have nothing, and need rations for survival. There is a case to be made, then, that if we were better supplied with information we would be able to distribute the available food much more effectively.

Basra Hassan

Save the Children Fund, Sudan

Dr Toole's presentation very nicely summarized the major nutritional problems refugees often encounter, and Dr Seaman has also pointed out very important points regarding refugees and the problems they are facing. I will highlight a few points from Dr Toole's presentation and paper, and make a few remarks.

Table 1 of Dr Toole's paper must have been striking to some of us -- to see that there are groups of refugees receiving adequate, well-balanced diets whilst living or located in very inaccessible places - receiving what they need through planes, whereas in places one can reach with trucks and spend a few thousand dollars, people are starving, and not receiving adequate rations. Who should be blamed for this? Is it the UN agencies, the donors, or those governments? Dr Seaman has touched on this point. As a refugee from East Africa, I really still require more explanation.

Dr Toole also discussed the nutritional status of refugees deteriorating while they are in the camps - there were examples of increases in the prevalence of protein energy malnutrition of under-5 children. In Somalia we have also had experiences of refugees' nutritional status deteriorating while they were in the camps. There was a outbreak of anaemia in children and women of child-bearing age -- in 1986 we discovered that 44 women who were newly delivered or pregnant had died within two months and we had 33 infants aged between two weeks and one month with no mothers, in a camp with a population of 35,000. Before this happened we had contacted all the UN agencies who were working with refugees in Somalia and informed them about the deficiencies in the rations and the problems these would be likely to cause, but nobody took our words seriously. However, when the situation began to deteriorate, and became visible, a dramatic change took place, both in the ration quality and the surveillance quality. The ration was improved in that beans were included on a regular basis and canned meat was brought for all - to be distributed as a supplementary ration for all pregnant and lactating women. More drugs of better quality were provided. Iron injections were included in the regimen for the treatment section. More tents were sent to open more in-patient clinics so that we could admit the severely anaemic women. A liver programme was established whereby all women whose haemoglobin was less than 7 g/dl were admitted, and those who were not very weak and who could take things orally were provided with 150-200g of liver on a daily basis. Iron tablets and vitamin C were also provided. Those who were unable to take the iron tablets that we were using at the time received an iron injection in place of the tablets, plus the liver, and those who were in a very serious situation, and who were in the last trimester were given blood transfusions.

Extensive surveys carried out at that time showed anaemia rates amongst children of 72% (cut-off of <10g/dl). We did not use the WHO cut-off of 11g/dl, because almost everybody would have fallen under that category. About 15% of the women were also severely anaemic. The subsequent surveys that have been done have shown dramatic improvements in all age groups.

I would also like to discuss the issue of rations - where the main discussion focusses on the quality and quantity of rations. If you go to the UNHCR or WFP offices in the countries which have refugees, their plans look fine. They can show you the amount of ration recommended, and the nutritional content of these rations, and these appear adequate on paper, but an important consideration is the regularity of the supply. The UNHCR and WFP representatives in the countries with refugees have been frustrated by the decision-making process. Many decisions about rations require HQ approval, and representatives will often tell you that HQ has not given approval, that someone important at HQ is away, and that they have to wait. Time passes and the problems increase, and there will come a time when little can be done about the situation. For example, one time when the malnutrition rate in under-5 children was very high in the camps in one region, we contacted the WFP representative, who told us that there was a policy decision that only malnourished children should receive the supplementary ration. We suggested that we give food to all the under-5 children - at that particular time we had food which could feed these people for three months - and we asked if it would be possible to speed up the arrival of the next food supply. We were told that the representative could not do anything unless the headquarters approved it. It is my opinion that similar things are happening in other countries, and this irregularity of the ration supply causes a lot of uncertainty and lack of faith on the part of the refugees.

The following is dialogue between two women, Miss X and Miss Y. Miss Y went to a registration centre and when she came back she met Miss X on the way.

X: "Where are you coming from?"
Y: "I am coming from the registration centre."
X: "What did you tell them?"
Y: "I told them about the members of the family."
X: "How many?"
Y: "Nine"
X: "You are foolish, you know. You are not intelligent enough. Why did you not double the number?"
Y: "I do not like lying and also it is against the religion."
X: "Do you want to starve the children? There are times the religion allows you to tell lies when these things touch on your survival."
So for refugees food is often survival, it is not for development. Even when food was required for survival in Somalia, there were times when some food was allocated to the development programme, and WFP were not able to switch the food from the development to the refugee programme. So, I wonder why we seem to be putting more emphasis on having good relations at governmental level while people are starving and suffering when food is available and could very easily we switched to those who need it most.

Another point that made by Dr Toole was the tackling of problems such as scurvy by introducing vegetable gardening and fish farming, etc. I do not think this can be applicable to all situations. For example, the Kenyans would be very happy if the Somali refugees in their country confined themselves to their wired area. And the camp is so crowded that vegetable gardening or any other kind of farming is simply not possible.

Scurvy was a big problem in Somalia, and a number of options have been tried in order to tackle the problem. One of them was the mass distribution of vitamin C tablets, and we found out that this was impractical or impossible. The whole staff working for the refugee health section would have spent all their time just distributing and counting the tablets. The other problem we faced was misuse of the tablets. For these people, tablets and medicine are only for the sick, and although we had offered a lot of education on the subject of who should take the tablets and when the tablets should be taken, people were still using them for headaches and for use when they were sick. We found many tablets just thrown away, and children were taking tablets meant for family members. If children liked the sour taste of the vitamin C, mothers would just give everything to the child rather than sharing them as prescribed. There was a lot of misuse and abuse related to the vitamin C tablets. The other thing we tried was distribution of grapefruits and limes and that was also impossible because of the logistics involved - a great deal of money was required to make this work.

We also thought of fortifying dried skimmed milk (an item in the ration) with vitamin C powder - as Dr Seaman has mentioned. For the first three weeks it seemed that it was working and the milk itself was acceptable - there were no complaints about the taste. We also did laboratory analysis of the fortified milk. Unfortunately, the whole project had to stop because of war and other problems in the country, and we were unable to assess extent of its success.

I would like to end my discussion by saying that for refugees, the UN is their parent, particularly the UNHCR and WFP people. They should think of themselves as the fathers of their families. A concerned father who left his children at home knowing that there was nothing left to feed them would think about and be very concerned about how he would feed his family, unlike a father who is not concerned. What is the use of a father who cannot feed his family?

Rita Bhatia

UN High Commissioner for Refugees

Dr Toole's presentation has shown that over the last ten years we have been seeing high mortality, high malnutrition and outbreaks of nutritional deficiency diseases, and Dr Hassan has discussed the dependency of refugees on international aid. Very recently, when I was in Ethiopia, a refugee came to me - a woman - and told me "the distribution point is my field and the ration card is my hoe". Refugees can be totally dependent. Even if they are peasants, that's where their food and living is.

I would like to discuss another very recent case study. In Sudan, we had about 20,000 - 30,000 male Ethiopian soldiers and ex-soldiers from the Ethiopian regime who took asylum in Sudan and were totally confined to a closed camp for over three weeks. They arrived in a good state of health, but soon developed scurvy, vitamin A malnutrition, and high mortality. There was very little water. They had access to only a small amount of cereal which was in the form of whole grains as there were no milling facilities. This population was totally dependent. At the end of this period, the soldiers were repatriated to Ethiopia, and the statement was made that this was one example of a successful repatriation of asylum seekers or refugees back to their home country. Nobody looked into what happened during the process.

What is wrong then? Why have we been going through these repeated failures? Is it due to lack of political will? Is it due to lack of resources? Is it due to poor management organization of relief services? From my own experience, and having been in the UN for a while, I do feel that there is a big communication gap between the technician and the policy-makers. Most of the food aid which is sent comes from the western world, and refugees can be totally dependent on it. We have very little choice about types of commodities, because aid is not in the form of cash - it is in the form of food - and so we have inadequate supplies, both in terms of quantity and quality. There has been inconsistency in the international response to many of the refugee emergencies, which is often based on political considerations and not on real needs. As we all know, refugees are dependent on this food aid. They often do not have access to markets, or to other barter systems, and what we give them is not enough to meet their needs. The consequences are obvious.

I would like to briefly mention logistical difficulties. As Dr Seaman said, even in some of the remotest places, logistical difficulties can be overcome. In Turkey and Iraq, because there was a political will, the logistical problems were solved by the use of helicopters and all kinds of planes. If there is a political will, I think there is a way. Logistics should not be used as an excuse for not delivering aid in adequate quantities and quality.

As Dr Seaman mentioned, there has been some agreement between the UN agencies, especially between UNHCR and WFP on basic minimum requirements. 1900 kcals has been recommended as the minimum requirement in emergency situations, but we have seen that people have been given less than half of that amount. In terms of the quality of food, which has already been mentioned by all my colleagues here, scurvy has been seen as a problem among refugees alone. I would like to address this issue again. Many experts have been doing a lot of work on vitamin A, anaemia and iodine, but there is no international strategy on prevention of scurvy. Pellagra is another micronutrient deficiency which has been seen in Malawi, among Mozambiquan refugees. Therefore, I would very much encourage and ask the group here to look into other micronutrient deficiencies, and not just to focus on the three or four major micronutrient deficiencies which have been discussed for the last ten or twenty years.

As technicians, we should be aware that our role is also to be advocates for refugees in terms of presentation and dissemination of information. Technicians should focus their advocacy efforts on promoting outcome oriented relief resources and assistance. As has been pointed out, there is no system whereby anyone can be held accountable if the proper information is not available. I think ongoing monitoring evaluation is very important, not just on the part of the UN, but also on the part of our other implementing partners.

I also feel that monetization should be encouraged among refugees, perhaps not in every situation, but in some situations where they have access to the market. One recent example is from Indonesia, on a small island where there are 20,000 Vietnamese refugees. They have free access to the markets, and they can go out of the island on the weekends. These kinds of camps are semi-closed. People are able to go out and look around. Thus, there are some situations where monetization should be tried and donors should be more open and flexible about who should be given cash - not for the whole food basket, but for perhaps some of the commodities which are available in the markets.

Another issue I would like to discuss is that of buffer stocks in the regions, which could be in the form of cash or in the form of kind. WFP has tried to set up regional stocks of food, but it did not work out very well because of logistical problems and infestation of food items. One suggestion which I would like to make is that perhaps buffer stocks of cash be set up. With cash one can easily go out and buy some of the required food items, and this way the normal procedure of UN which involves waiting for a green light from Headquarters could be avoided, and the procurements could be made at regional level.

Statement to Organizational Committee, 27 March 1992, by John Mason, Technical Secretary, ACC/SCN, Concerning the SCN's Report on Nutrition, Refugees, and Displaced Persons

"The SCN had first become aware of the nutrition crisis amongst refugees because of a conference held in 1988, organized by WHO and UNHCR, under SCN auspices. This conference had been aware of the difficulties of meeting refugees' nutrition needs, and had put forward a statement to the SCN, which subsequently went to the ACC. I will quote briefly from this statement. We said that the problem with famine and disaster had resulted in unprecedented numbers of people depending for their survival upon international food aid, sometimes for prolonged periods of time. It was noted that although the total volume of emergency resources had been generous, this had nonetheless proved painfully inadequate to meet escalating needs, and indeed had at times failed to reach the intended beneficiaries due to severe constraints in recipient countries. The meeting noted that consequently the rations provided very often result in a seriously insufficient and unbalanced diet.

"The SCN had requested the ACC to bring this tragic situation urgently to the attention of donor governments. I am glad to be able to inform the OC that we understand that this did indeed have some effect. The statement was passed from ACC to ECOSOC and thence to a number of member governments, and we understand from participants in the SCN that some awareness had been raised, and indeed some action taken.

"The Sub-Committee had been kept aware of the nutrition crisis in the period since 1989, and at the Symposium held at the World Food Programme at the time of the recent Session in February, one of the three themes was protecting the nutrition of refugees and displaced persons with food aid. During this part of the Symposium, the Sub-Committee heard reports that nutrition in refugee camps was no better now than it had been the last time the situation was considered. It heard of increasing numbers of refugees certainly, so that with no improvement in the prevalence of malnutrition, the number of people suffering must have increased significantly.

"Perhaps the most shocking information for the Sub-Committee were two aspects. First was that during refugees' slays in camps, in sight of help, people remained or become severely underfed, and some died as a result.

"Secondly, that epidemic outbreaks of micronutrient deficiency diseases - scurvy, pellagra, beri-beri, which were thought to have been eliminated in the world - were now re-emerging.

"In the serious discussion that followed, the Sub-Committee focussed on two improvements in the system. The first of these was to improve the clarity of the accountability, who is responsible for this situation and more important who can prevent it happening. Secondly, and related to this, monitoring systems need improvement. It was said that although more resources were needed, it was also the case that better use of resources would be feasible, if the necessary information was available, and the necessary decisions were made. It was noted that all too often information got attention through mass media, and then necessary decisions were made: this could be greatly improved to ensure, as the statement says, "a more timely and effective response to the nutritional needs of refugees and displaced persons".

"It was felt that the SCN was an appropriate forum to identify such deficiencies - there was a collective need to take urgent action, without singling out anyone's particular role.

"These specific recommendations were carefully thought out and worded - as was the whole statement - initially by a group led by UNICEF, drawing on SCN members, and then reviewed by the SCN Executive Session, and the Subcommittee in plenary. The specific recommendations refer most of all to monitoring, and reporting to those who can take action and be accountable for that action. They include the setting of goals for alleviating malnutrition among refugees and displaced persons.

"The SCN had listened to Ms Basra Hassan, a nutritionist from Somalia who had contributed to the 1988 meeting, and who is now working in Darfur, Sudan, for Save the Children Fund. She herself had recently been a refugee from Somalia. She said: "You have to realize that the UN is seen as a parent to refugees - who else is there? And what use is a parent who cannot feed their children?"

"Finally, the Sub-Committee recommended - appealed might be a better word - to the ACC through the OC to help."

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